Tarrant �itC;�l�i�i�
MAR 14 2Q13
NOTICE OF CLAIM FORM to the City of Saint Paul,�ll�:�.��a
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipa[ity...sha[[cause to be presented to the
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name�Cf,('�Q�) Middle Initial �-• � Last Name � Ct('(Yl N�
Company or Business Name
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address � 3�O , � i O� �lS'�, • �O .
� `�;
City� . �[��s�L State V� �� Zip Code S� l •
Daytime Phone(�Sy )�•�Cell Phone( ) - Evening Telephone(�����
Date of Accidentl Injury or Date Discovered `1 � Time •��=am pm
Please state, in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or how you
feel the City of Saint aul or its empl yees are involved and/or resp nsible fo�r your damages. C •
_ � �A., _ Q, ,
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Please check the box(es) hat most closely represent the r�ason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
�My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim youu need to include coqies oF all applicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
�Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please comnlete this section _��
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name Qf park or facility,
c sest landmark,etc. Please be as detailed as ossible. If necessary, attach a diagram. - �
w�^N a� R a� �
�"'c�.s�;�y ic��'��
Please indicate the amount you are seeking in compensataon or what you would like the City to do to resolve t�iis claim
to your satisfaction. � ��� � l
Vehicle Claims- lease com lete this section ' ❑ check box if this section does not a 1
Your Vehicle: Year�Make � Model � 7(�
License Plate Number �� � State�PS Color �.�- r�e
Registered Owner ���' �'�T
Driver of Vehicle �
Area Damaged ��'
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please complete this section ,�check box if this section does not apnlv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s): ;
Address ' Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
,�Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed � ���-� Z��� �
Print the Name of the Person who Completed this Form: �j,(�(�N � � ! �rf�ti�
Signature of Person Making the Claim:
� � �
Revised February 2011
Customer Invoice TIRES PLUS Service Advisor:
101963 MIDWAY 02 ALEX
03/11/2013 300 SNELLING AVE N 651.644.1975
SAINT PAUL, MN. 55104-5330
1998 VOLVO V70 '
TARRANT, KAREN 5-2319 2.3L DOHC
1361 CRIER AVE S Lic#: NXY306 MN Vin#:
SAINT PAUL, MN 55116 In: 03/11/13 8:27AM Mileage: 159,711
651.698.5506 Out: 03/11/13 5:24PM
Store#244226 RETAIL SALE
Rev Hist Unit E�ended Job
Description__ /Article# ID Qty Price Price_ _ Total
--- - - - -- __ - ------ -- --- _ _-- . _- - --- - ---- .
COURTESY CHECK 02
COURTESY CHECK 7046930 55NS 1 N/C N/C
IVIICHELIN'TIRE PACKAGE 1 02 310.94
NEW TIRE WHEEL BALANCE PARTS 7018708 55TN 2 3.99 7.98
NEW TIRE WHEEL BALANCE LABOR 7018716 55NS 2 9.00 18.00
RUBBER VALVE STEM 7015040 55TN 2 2.50 5.00
SCRAP T1RE RECYCLING;,CHARGE(1) 7075078 55TN -,:2 �;Z.99 , . 5 98,..
TIRE INSTALLATIOI�' � � � ����� , � 7015�16���55NS��: �� f:2 � ���N/C � N/C ����
7099716 2055516 MICHELIN PRIMACY MXV4 H RATED 7099716-55TN ` 2 136.99 ' 273.98
DOT# HNWC011X4212
DOT#, HNWC011X4212
Technician(s):
,,
� 55' NATE CHANDLER
Payment History: Summary:
Visa 7691 334.35 01558C Parts 286.96
Total Tendered 334.35 - _ Labor 23:98
Shop Supplies 1.08
Sub-Total 312.02
Tax(7.625%) 22.33
� Total $334.35
I have received the above goods and/or services. If this is a credit
card purchase, I agree to pay and comply with my cardholder
agreement with the issuer.
Rev
Revision His�ry: Amt Init
Customer Signature 1)03/11/2013' 09:12AM 305.84 TARRANT, KAREN IN PERSON
Initial here to indicate you have received
the Tire Limited Warranty Book.
A//parts are new unless otherwise specified.
� I acknowledge notice and oral approval of
an increase in the original estimated price.
Signature or Initials
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